Knolls West Post Acute LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set, (MDS- a federally required resident assessment tool used to plan care and track clinical status) for one of seven sampled residents (Resident 64) reviewed for MDS coding accuracy when the facility inaccurately, documented Resident 64 received antibiotics in February 2025, despite no physician's orders showing antibiotic use. This failure has the potential to cause poor care planning and inaccurate understanding of Resident 64's health, increasing the risk Resident 64's needs will not be met. Findings: During a review Resident 64's admission Record (contains demographic and medical information) indicated Resident 64 was admitted to the facility on [DATE], with the admitted diagnosis of peripheral vascular disease (poor blood circulation), stiffness of right ankle (limited movement), stiffness of left ankle (limited movement) During a review of Resident 64's MDS (Minimum Data Set) Section N0300-Medications,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to update Resident 84's Pre-admission Screening and Resident Review (PASRR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in nursing homes for long term care) when Resident 84 did not have her diagnosis of schizophrenia (a chronic mental disorder that affects how a person thinks, feels, and behaves) included in the PASRR assessment used to admit Resident 84 into the skilled nursing facility. This failure had the potential to result in Resident 84 to not be accurately assessed regarding the need for treatment and services in alternate care settings to better suite the needs of Resident 84. Findings: During a review of Resident 84's admission Record (contains medical and demographic information), the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of three residents (Resident 59) sampled for rehabilitative and restorative services when Resident 59 did not receive physical therapy five times a week as ordered by the physician. This failure had the potential to cause a decrease in Resident 59 overall functioning or the inability for Resident 59 to reach his/her highest level of functioning. Findings: During a review of Resident 59's face sheet (contains medical and demographic information), the face sheet indicated Resident 59 was admitted on [DATE], with diagnoses which included polyneuropathy (condition in which multiple nerves are damaged or dysfunctional on both sides of the body, often leading to symptoms like weakness, numbness, and burning pain), generalized osteoarthritis (breakdown of cartilage in multiple joints, leading to pain, stiffness, and decreased joint function), heart failure (the heart not being able to fill…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the physician's orders for heel protector boots for one of seven sampled residents (Resident 64) reviewed for skin integrity when Resident 64 was observed without the ordered heel protectors and was documented to have develop a deep tissue injury (DTI). This failure has the potential to contribute to Resident 64 delayed wound healing (slower recovery of injured skin and tissue), pain (physical discomfort), and further skin breakdown (worsening skin condition leading to open wounds). Findings: During a review Resident 64's admission Record (contains demographic and medical information) indicated Resident 64 was admitted to the facility on [DATE], with the admitted diagnosis of peripheral vascular disease (poor blood circulation), stiffness of right ankle (limited movement), stiffness of left ankle (limited movement). During an observation on May 19, 2025, at 10:50 AM inside Resident 64's room, Resident 64 was lying down on her back…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the attending physician conducted an initial comprehensive visit within the first 30 days after admission, for two sampled residents under a Medicare Part A&B stay (Resident 19 and 22). This failure has the potential to place Residents 19 and 22 at risk for serious harm or death. Findings: 1. A review of Resident 19's face sheet (demographic information) indicates Resident 19 is an [AGE] year-old female, admitted from the hospital on March 12, 2025, with diagnoses which include arthritis (redness, painful, swollen joint), atrial fibrillation (irregular rhythm that disrupts the normal flow of blood through the heart), hyperlipidemia (having too much fat in the blood), dementia (group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), nutritional deficiency (occurs when someone doesn't get enough of the essential nutrients their body needs to function properly,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure staff signed the narcotic reconciliation log when discrepancies were found in two of four narcotic reconciliation logbooks. This failure had the potential to result in improper administration of medication and dosage, increasing risk of adverse drug reactions, and possible harm to 106 vulnerable patients. Findings: During a concurrent observation and interview with Registered Nurse Supervisor 3 (RNS 3), on May 21, 2025, at 5:07 AM, in the hallway, the narcotic reconciliation logbook in station 4 was inspected. The dates: March 7, 18, 19, 26; April 13, 17, 24; May 14, 20, 21, 2025 were missing signatures. RNS 3 confirmed the dates were missing signatures. During a concurrent observation and interview with Licensed Vocational Nurse 5 (LVN 5), on May 21, 2025, at 1:04 PM, in the hallway, the narcotic reconciliation logbook in station 1 was inspected. The dates: March 9, 10, 11, 12, 16, 22, 25, 26, 29; May 19, 20, 21, 2025 were missing signatures. LVN 5 confirmed the dates were missing signatures. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. One Medication Storage room and one Medication Refrigerator located at Nursing station 4 was found unlocked, and 2. One medication refrigerator located at Nursing station 1 was found unlocked. This failure has the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 103 residents. Findings: 1. During a concurrent observation and interview on May 19, 2025, at 8:44 AM, the Medication Storage room located at the Nursing station 4 was accessed without a key by Licensed Vocational Nurse 1 (LVN 1). Inside the Medication Storage room, the Medication Refrigerator displays lock latches in place and no padlock. The unlocked medication refrigerator contains vials of injectable Ativan (a medication used to treat anxiety) and Haldol (a medication used to treat mental disorders), several Insulin (a medication used to treat high blood sugar) pens, and one Emergency Kit. The LVN 1 stated that he started working at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it followed its infection control program when: 1. A Registered nurse Supervisor 3 (RNS 3) did not perform hand hygiene (hand washing or the use of alcohol based hand sanitizer) after performing a blood glucose check (procedure done to check the level of sugar in the blood and requires a pinprick blood sample). This failure had the potential for the spread of infectious blood borne pathogens (bacteria and viruses which can cause disease and illness) and the spread of infectious microorganisms from one patient to another in a vulnerable population of 106 patients. 2. There was a bag of intravenous antibiotics (antibiotics administered into the veins) and IV tubing set (disposable IV set used to administer medication intravenously) dated [DATE] and [DATE], left at Patient 33 bedside on [DATE] (23 days after it was used). This failure had the potential for inadvertent use of an expired IV tubing set or antibiotic bag which was past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow its policy and procedure to ensure a comprehensive care plan was developed for one of four sample residents (Resident 1) when Resident 1 was not provided a plan of care to meet Resident 1 ' s nutritional needs. This failure had the potential to place a clinically compromised resident (Resident 1 ' s) overall health and safety at risk. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included, dementia (loss of memory), cerebrovascular disease (conditions that affect blood flow to your brain), and muscle weakness generalized (loss of strength in your muscles). A review of Resident 1 ' s clinical record, POLST indicated, Long-term artificial nutrition, including feeding tubes. During an interview on March 26, 2025, at 1:05 PM with the Licensed Vocational Nurse (LVN 1), LVN 1 stated, We usually follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (injury to skin/tissue from prolonged pressure on the skin) for one of three sampled residents (Resident 1). This failure resulted on resident 1 acquired pressure ulcer to coccyx left and right buttocks (lower back/spine) developed while in the facility. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (problem in brain caused by chemical imbalance in blood), down syndrome ( a genetic disorder causing developmental and intellectual delays), sepsis ( a life threatening complication of an infection), osteomyelitis of right hand (bone infection) and cellulitis of right finger (bacterial skin infection). During a concurrent interview and record review of Resident 1 ' s clinical records with Treatment Nurse 1 on January 6, 2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to follow their policy and procedure on medication administration when a Licensed Vocational Nurse failed to administer Nifedipine (medication use to lower blood pressure) ordered by physician to one of three sampled Residents (Resident 1). This failure has a potential to place a clinically compromised Resident 1 ' s health and safety at risk. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, cerebral infarction ( damage to tissues in the brain due to a loss of oxygen to the area), hypertension ( High blood pressure), gastroesophageal reflux ( involuntary back flow of stomach contents back into the esophagus or food pipe ), rheumatoid arthritis (chronic autoimmune disease that causes inflammation and damage to the joints), malignant neoplasm of female breast ( a cancerous tumor that develops in the breast tissue ), polyneuropathy (affects nerves that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility failed to follow their policy by not following physician ' s order to provide physical therapy five times a week for one of three sampled residents (Resident 1). This failure had the potential to cause contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) and decreased mobility to Resident 1, by negatively affecting his physical health, mental and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included, wedge compression fracture of first lumbar vertebra (fracture occurs when the actually collapses to the front part of the vertebra and form a wedge shape), polyneuropathy( damage to multiple nerves outside of the brain and affects several nerve in different parts of the body at the same time), hypertension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure licensed vocational nurse (LVN 1) perform medications administration according to the facility's policies and procedures (P&P) for one of four sample residents (Resident 1) when during resident 1's medication pass, the surveyor noticed that the LVN pre-signed the medication before administering it, failed to check the medication's expiration date, and failed to record on Resident 1's MAR the reason why Amlodipine (a medication used to treat high blood pressure) not available, believing that she could have borrowed Amlodipine from another resident for Resident 1. This deficient practice had the potential to adversely affect the health and safety of Resident 1 who is clinically compromised. Findings: During the review of Resident 1's admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included Atherosclerotic heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that an allegation of physical abuse for one of three sampled residents (Resident 1) was reported to the local, state, and federal agencies immediately in accordance with their facility's policy. This failure had the potential for the alleged abuse to go uninvestigated and unreported thereby increasing the chances of health, safety, and psychosocial harm to Resident 1. Findings: During an interview with Administrator on September 5, 2024, at 2:30 PM, he stated that he did not feel there was enough evidence based on interviews with witnesses and resident to report it to the state. Stated the son came to him highly upset and he said he felt LVN 1 ( Licensed Vocational Nurse) threw resident on the ground, states what LVN 1 said to him resident was threatening to leave the building and I redirected him and told him to go back to his room He stated I don ' t know why she started to stop him at the nurses station, I usually wait until they get to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect residents from potential abuse and mistreatment, in a universe of 112 residents, when the facility employed a Licensed Vocational Nurse (LVN 1) with a disciplinary action (a formal process that imposes consequences or corrective measures for misconduct or violations of professional standards), in effect, against her professional license. This failure had the potential to cause residents to suffer abuse and mistreatment. Findings: An unannounced visit was made to the facility on September 10, 2024, at 10:46 AM, to investigate a facility reported incident regarding an allegation of physical abuse and deprivation of services by LVN 1. During a concurrent interview and record review on September 10, 2024, at 12:39 PM, with a Director of Staff Development (DSD), LVN 1 ' s personnel file and professional license was reviewed. The DSD stated LVN 1 ' s date of hire was February 14, 2024. A review of LVN 1 ' s professional license, dated expiration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to follow their Policy and Procedure when the licensed nurse failed to document the refusal of medication for one of three sampled Residents (Resident 1). This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When not receiving the necessary medication as prescribed by the physician. Findings: During a review of Resident 1s admission Record (general demographics), indicates being admitted to facility April 15, 2024 with diagnosis (DX) of Polyneuropathy (multiple nerves are damage), gastroenteritis and colitis ( inflammation in the digestive tract), bipolar disorder (episodes of mood swings), muscle weakness ( decrease in strength), dysphagia ( difficulty in swallowing), type II diabetes mellitus (sugar imbalance in body), anxiety (feeling of worry), psychotic disorder ( disconnection from reality), and hepatomegaly (enlargement of liver). During interview of Resident 1 on June 18, 2022, at 1:50 pm, Resident in wheelchair, is alert and oriented. Resident 1 stated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and facility policy review, the facility failed to properly store and date foods items in 1 (Unit 1 and Unit 2) of 2 nourishment refrigerators in the facility. Findings included: A facility policy titled, Foods Brought by Family and Visitors / Food Storage, revised in January 2022, revealed, 5. Family and other visitors can bring food to be consumed by the resident. a. Non-perishable foods and food appropriate to store at room temperature will be stored in resident room in re-sealable containers. These foods will be discarded on or before the use by' date. If no, use by date is provided, item will be labeled with a use by date 3 days from when the item was received. b. Perishable foods from outside must be consumed, discarded or taken home with visitors on same day the food is brought. Refrigeration is not available for resident's food/leftovers. Intact family prepared meals are okay to be stored for 3 days. c. Intact fresh fruit may be stored unsealed. During an observation of the Unit 1 and Unit 2 nourishment refrigerator on 05/22/2024 at 9:45 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of comprehensive Minimum Data Set (MDS) assessments for 3 (Residents #16, #69, and #79) of 8 sampled residents reviewed for resident assessments. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised in January 2022, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Per the policy, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis unless an SCSA [significant change in status assessment] or an SCPA [significant correction to prior assessment] has been completed since the most recert…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, document review, and interviews, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 3 (Residents #58, #96, and #109) of 8 sampled residents reviewed for resident assessments. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised in January 2022, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Per the policy, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to change oxygen tubing weekly as ordered by the physician and store respiratory equipment when not in use as directed by the facility's policy for 1 (Resident #188) of 1 sampled resident reviewed for respiratory care. Findings included: A facility policy titled, Policy and Procedures on Oxygen Therapy, dated August 2017, revealed, 8. When not in use, nasal cannula shall be placed and secured in a clean plastic bag to avoid contamination. An admission Record revealed the facility readmitted the resident on 03/22/2024, with diagnoses to include chronic obstructive pulmonary disease (COPD), heart failure, and pleural effusion (fluid build-up around the lungs). A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/2024, revealed Resident #188 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used oxygen therapy. Resident #188's care plan, initiated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, the facility failed to indicate the duration of an as-needed anti-anxiety medication for 1 (Resident #20) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Policy and Procedure on Psychotropic Medications, dated October 2014, revealed, The facility shall use a psychotherapeutic drug or chemical restraint on residents only as part of a plan to eliminate or modify symptoms for which the drug is prescribed, and only on the written order of a physician that specifies the duration of the use of the medication and the circumstances under which the medication is to be used and only if the resident, or his/her surrogate decision maker has given consent to the use of the medication Per the policy, 4. When a decision is reached and made by the interdisciplinary team and the physician that the resident needs the psychotropic medication/chemical restraint, a written physician's order that specifies the duration of the use of the medication and the circumstances under which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to uphold residents' rights for visitation for all 105 residents residing within the facility when the facility was restricting visitors by requiring visitors to be tested for COVID-19 (an illness caused by a virus) prior to entering the facility, charging visitors five dollars for COVID-19 tests, limiting visitation time to 1 hour, and by posting limiting visitation hours as was all specified by the Visiting Policy posted at the reception desk (main entrance) of the facility. These failures resulted in the infringement of the rights for visitation of all 105 residents by potentially deterring visitors as a result of the posted requirements. In addition, this failure resulted in the visitor of one resident (Resident 162) to demonstrate verbal frustration regarding the visitation restrictions. Findings: During a concurrent observation and interview on January 17, 2023, at 1:06 PM, at the facilities main entrance, a visitor for Resident 162 (RV 162) was visibly frustrated and stated during a visit to the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to designate a qualified Director of Food Services to provide the daily oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of oversight in the operations of the dietary department and supervision of staff which could lead to poor quality of services in the department. Findings: During an interview on December 5, 2022, at 8:20 A.M., with the Director of Food Services, (DFS) , DFS stated she was the Director of Food Services and runs the day-to-day operations of the kitchen. During further interview on December 5, 2022, at 8: 45 A.M., with the DFS, the DFS stated she was not a certified dietary manager because she failed to pass the test twice given by the Dietary Managers Association (DMA). The DFS also stated she had no bachelor's degree in food and nutrition or completed an approved dietary service training program as required by regulation. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label and discard medications for three of three sampled residents (Residents 20, 5 and 56) when: 1. For Resident 20 there were two vials of Humulin R (a short-acting insulin that starts to work in 30 minutes and lasts for several hours to control a resident's blood sugar) 100 units (a unit of measurement)/ (in) one ml (milliliters-a unit of measurement) insulin which had not been labeled or removed as follows: a. Vial #1 (a small container of glass for holding liquids, number one) indicated an opened date of September 19, 2022. On December 8, 2022, Vial #1 was in the medication cart and available for use. Vial #1 had not been discarded 28 days after the opened date as indicated on the pharmacy label. b. Vial #2 was open but did not indicate an opened date. 2. For Resident 5, a vial (a small container of glass for holding liquids) of Humulin R (a short-acting insulin that starts to work in 30 minutes and lasts for several hours to control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow the menu when pureed (smooth, pudding consistency food that does nt require chewing) peaches were served instead of the pureed peach cobbler as indicated in the lunch menu for 4 of 109 residents. This failure had the potential to disregard resident's food choices when a dessert substitute was served during lunch. Findings: During a concurrent observation and interview on December 8, 2022, at 1:15 PM, with the Director of Food Service (DFS) in the facility conference room, the texture and taste of the pureed desert was observed to be different. The DFS tasted the regular dessert and the pureed dessert, and she stated, Yes, the taste and texture between the two are different. During a concurrent interview and record review on December 8, 2022, at 2:40 PM, with Dietary Aid 3 (DA3) , Recipe Name: Pureed Dessert, undated was reviewed. It indicated, Ingredients, Dessert , Regular Portion . Directions:1. Remove portions required from regular prepared recipe. Place in food processor and process until smooth.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide services for the ordered number of frequencies for specialized rehabilitative services as determined by Physical Therapy for 2 Residents (29 and 358) as ordered by the physician. These failures had the potential to cause a decline in the residents' functional status and/or prohibit the optimization of their functional status. Findings: 1. During a concurrent observation and interview on December 6, 2022, at 3:19 PM Resident 358 stated she has left sided weakness due to a stroke and had not been getting physical therapy that she should be getting, because the therapist has been gone on vacation. Resident 358 was observed lying in bed, with maximum assistance needed to reach for items at bedside table. A record review of Resident 358's Physical Therapy Evaluation and Plan of Treatment, for the certification period of October 27, 2022, through November 25, 2022, listed the following: Diagnoses include Muscle weakness, and Hemiplegia following a cerebral infarction (paralysis of one side of body due to an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change assessment within 14 days for one resident, Resident 8, reviewed for hospice services. This failure had the potential to delay identification and implementation of the resident's care and support needs. Findings: During a review of Resident 8's clinical record, the admission Record (a document containing clinical and demographic information) was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included heart failure (a weakened heart condition), chronic kidney disease stage III (kidney malfunctioning disease that has progressed to the third of five stages), and moderate protein-calorie malnutrition (when not enough protein or calories are consumed to meet nutritional needs). The clinical record further indicated that the resident was admitted under hospice services on December 10, 2021. During a concurrent interview and record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately identify on three different Minimum Data Set (MDS) (a computerized clinical assessment) assessments for one resident, Resident 8, that the resident was receiving hospice (a program providing services for the care of terminally ill residents and their family) services. This failure had the potential to delay identification and implementation of the resident's care and support needs. Findings: During a review of Resident 8's clinical record, the admission Record (a document containing clinical and demographic information) was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included heart failure (a weakened heart condition), chronic kidney disease stage III (kidney malfunctioning disease that has progressed to the third of five stages), and moderate protein-calorie malnutrition (when not enough protein or calories are consumed to meet nutritional needs). The clinical record further indicated that the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an individualized comprehensive care plan was initiated for one out of 32 residents (Resident 57) for care and precautions to be taken for a resident with a gastrostomy (insertion of tube through the abdomen wall through which liquid nourishments and medications can be administered) feeding . This failure had the potential for Resident 57 to develop nutritional risks from unidentified care concerns or place him at risk for aspiration (inhalation of food or fluid into the lungs) if preventive measures were not care planned. Findings: During a review of Resident 57's admission Record, (contains demographic and medical information), undated, indicated Resident 57 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), dementia (a group of conditions affecting the ability to remember, think or make decisions), and hemiplegia and hemiparesis following cerebral infarction (muscle weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide colostomy (an opening for the large intestine through the abdomen where stool is passed) care for one out of 32 residents (Resident 67). This failure had the potential to cause Resident 67 to suffer increased infection, pain, and unpleasant odors due to the colostomy bag not being emptied or skin not being cleansed to prevent breakdown. FINIDNGS During a review of Resident 67's admission Record, (contains demographic and medical information), undated, indicated Resident 67 was admitted to the facility on [DATE], with diagnoses that included heart failure (a condition in which the heart does not pump blood adequately), end stage renal disease (a condition in which the kidney does not function), dysphagia (inability to swallow) and bed confinement status (inability to tolerate activity out of bed). During an interview on December 7, 2022, at 8:45 AM, Resident 67 stated she had been waiting for two hours for the treatment nurse to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 44) when: For Resident 44, a significant weight loss of 5.65% (percent) in 1 (one) month and a continued weight loss of 11.29% in approximately two plus months was identified, but a Weight Change Review, was not documented, Resident 44's care plan was not updated to address Resident 44's refusal to eat, or the impact of nutritional deficits on wound healing for a Deep Tissue Injury (DTI- a form of pressure ulcer. Pressure ulcers are localized areas of tissue damage that develop because of prolonged pressure on bony prominences-areas of bone that are close to the skin's surface). Resident 44 was not placed on weekly weights and Resident 44's DTI was not included in Resident 44's Nutritional Assessments dated October 5, 2022, October 12, 2022, October 19, 2022, and November 9, 2022. These failures to address Resident 44's weight loss had the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician of a missed dialysis (a process of filtering out the blood through a machine, when the kidneys are unable to do it by themselves) treatment for one resident, Resident 408. This failure had the potential for the resident to experience serious side effects due to the build up of toxins in the blood that the dialysis filters out, high blood pressure and fluid retention. Findings: During a review of the clinical record for Resident 408, the admission Record (a document containing clinical and demographic information) was reviewed. Resident 408 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney disease that has progressed to the last of five stages, usually requiring dialysis), cellulitis (skin infection) of both lower extremities, hypertension (high blood pressure), and congestive heart failure (a weakened heart condition that causes fluid buildup in the body). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one Licensed Vocational Nurse (LVN 7) demonstrated competency when she prepared insulin (a medication used to help control blood sugar levels) in accordance with manufacturers recommendations when she drew up insulin from a prefilled insulin syringe into a separate insulin syringe for administration to Resident A. This failure had the potential for the increased risk of medication errors, and to alter the efficacy (ability to produce desired effects) and accuracy of the prefilled insulin pen for subsequent injections. Findings: During an observation on December 11, 2022, at 5:01 AM, with Licensed Vocational Nurse 7 (LVN 7), LVN 7 was preparing medications for administration to Resident A. During the preparation of Insulin Aspart (a short acting insulin), LVN 7 used a separate insulin syringe and inserted the needle into the tip of the Insulin Aspart [brand name of insulin pen] prefilled syringe and withdrew 6 units of insulin for administration to Resident A. LVN 7 then subcutaneously (into the fatty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one staff member (Licensed Vocational Nurse 5 - LVN 5) followed the facility policy and procedure for medication administration when the nurse did not review the pharmacy medication label (a label applied to the medication with information regarding who the medication belongs to, the name of the medication, the dose etc) for insulin (a medication used to help regulate blood sugar levels) prior to attempting to administer the medication to Resident 56. This failure had the potential to result in physical harm to Resident 56 as a result of the increased risk of a medication error when the five rights of medication administration (five principles used to help prevent medication errors by verifying: right medication, right dose, right time, right route, right patient) were not verified prior to administration to the resident. Findings: During a review of Resident 56's medical record, the admission Record (contains medical and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure clinical records for six residents (Residents 3, 28, 64, 67, 78, and 161) were complete and accurate when: 1. The Physician's Orders for Life Sustaining Treatment (POLST - Written medical orders that addresses a limited number of critical medical decisions) for five of five residents (Residents 3, 28, 64, 67, and 78) reviewed for advance directives (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) was left blank regarding whether or not an advance directive existed for the residents. This failure had the potential to result in a delay of treatment for the residents as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. 2. Certified Nursing Assistants did not document bowel movements (stooling) for Resident 161 between December 1, 2022, and December 6, 2022, in accordance with the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide evidence the Medical Director or a designee, attended Quality Assurance and Process Improvement (QAPI) meetings for the first quarter (January 1 - March 31) and second quarter (April 1 - June 30) of 2022. This failure resulted in the facilities inability to provide evidence the Medical Director or designee (a required QAPI member) had participation in, and had an opportunity to provide meaningful insight, during required quality assurance meetings regarding facility operations. Findings: During an interview on December 13, 2022, at 5:26 PM, with the Administrator (ADMIN), the ADMIN stated one of the purposes of the QAPI committee was to decide on which facility problem-prone areas the facility would work on improving based upon data the QAPI team was collecting, and the ongoing concerns based on the severity of the identified issues and overall impact on the resident population. During an interview on December 13, 2022, at 5:51 PM, with the ADMIN, the ADMIN stated the required QAPI committee members included the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. The Facility did not ensure that visitors of Resident 158, who had clostridium difficile (C-Diff- a bacteria causing diarrhea and infection in the intestines) were educated about isolation precautions, proper protective equipment, and hand hygiene. 2. The facility did not ensure that proper hand hygiene was done before and after providing direct care for Residents 409 and 72. 3. The facility did not remove Resident 49's Peripherally Inserted Central Catheter (PICC - a thin, long catheter that is inserted through a vein in the upper arm and passed through to the larger veins near the heart, for administration of medications or liquid nutrition) after an intravenous (IV) antibiotic was completed. These failures had the potential to cause and spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to residents and staff in the facility. Findings: 1. During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.